Understanding the occupational and organizational boundaries to safe hospital discharge

Abstract

Objective: Safe hospital discharge relies upon communication and coordination across multiple occupational and organizational boundaries. Our aim was to understand how these boundaries can exacerbate health system complexity and represent latent sociocultural threats to safe discharge. Methods: An ethnographic study was conducted in two local health and social care systems (health economies) in England, focusing on two clinical areas: stroke and hip fracture patients. Data collection involved 345 hours of observations and 220 semi-structured interviews with health and social care professionals, patients and their lay carers. Results: Hospital discharge involves a dynamic network of interactions between heterogeneous health and social care actors, each characterized by divergent ways of organizing discharge activities; cultures of collaboration and interaction and understanding of what discharge involves and how it contributes to patient recovery. These interrelated dimensions elaborate the occupational and organisational boundaries that can influence communication and coordination in hospital discharge. Conclusions: Hospital discharge relies upon the coordination of multiple actors working across occupational and organizational boundaries. Attention to the sociocultural boundaries that influence communication and coordination can help inform interventions that might support enhanced discharge safety.

Health professionals’ perspectives on the discharge process and continuity of care for stroke survivors discharged home in regional Australia: A qualitative, descriptive study

“…This is similar to the recent National Stroke Audit data that reported, although 75% of stroke survivors needed ongoing rehabilitation, only 46% were referred to rehabilitation services (Stroke Foundation, ). The pressure to discharge patients quickly can mean that they do not receive information from all team members before they are sent home, and this is confirmed by other studies (Kable et al, ; Waring et al, ).…”

Safety lessons: shifting paradigms and new directions for patient safety research

“…Increased attention is given to the issue of 'context' in shaping safety and safety improvements, but the totality of the health and care system is rarely considered, especially the influence of wider institutional forces, political and regulatory pressures and the inherent complexity of the care system. 36 The Francis report, for example, highlights the bureaucratic burden of overregulation and its potential perverse influence of day-today clinical practices, where doing the system's business comes ahead of patient care.…”

“…Where Mannion and colleagues bring new understanding to the role of senior management and organisational governance, Waring and colleagues examine the threats to patient safety found between care organisations and processes. 36 Specifically, they focus on the realities of hospital discharge or care transition for stroke and hip fracture patients, providing rich insights into the hidden interdependencies and partial sightlines of different parts of the system 'framed by boundaries of knowledge, culture and organisation'. In particular, this contribution reframes analysis of patient safety beyond the clinical micro-system and linear error chains, to consider instead how safety is shaped by the interdependencies of actors and agencies working in a complex system.…”

Patients' perspectives on care pathways and informed shared decision making in the transition between psychiatric hospitalization and the community

“…A shared decision‐making process can be an especially difficult experience for those patients with profound mental health challenges. Health care professionals need to identify to what degree patients can or are able to engage with decision making, not least in the context of care transitions that involve a multitude of health and social care professionals working within and across different organizational boundaries . The movement of patients into and out of acute inpatient mental health wards is also particularly complex because of the potential for coercive practice.…”